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A Brazilian Football Player Still on the Pitch After 10 Years of Parkinson's Disease with Severe Freezing of Gait

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Authors: Thiago Cardoso Vale MD, MS, José Luiz Pedroso MD, PhD, Orlando Graziani Barsottini MD, PhD and Andrew John Lees MD, FRCP, FMedSci

Article first published online:  6 DEC 2014 | DOI: 10.1002/mdc3.12110

Freezing of gait (FOG) in Parkinson's disease (PD) is a difficult problem to manage pharmacologically, but has been known to respond favorably to sensory tricks and cues that can be auditory, visual, or even tactile (sensory/proprioceptive), such as kicking a football,[1, 2] as presented here, in a 63-year-old former professional football player. At the age of 16, the patient was scouted for the Palmeiras Sport Club and then played football in the national league until the age of 21, when he suffered a serious contusion to his tibia, preventing him from training or playing for the next 3 years and eventually forcing him to retire. He was still playing football when he was diagnosed with PD at the age of 54. At the age of 60, he developed debilitating FOG, during which he would develop incapacitating motor blocks lasting up to a minute and an inability to take more than a few shuffling steps. He had no motor fluctuations, dyskinesia, or cognitive impairment (Mini–Mental State Examination of 30/30). His medication was levodopa/benserazide 800 mg/day, pramipexole 03 mg/day, amantadine 200 mg/day, and entacapone 800 mg/day. Higher doses of l-dopa (1,200 mg/day) and pramipexole (4.5 mg/day) did not lead to any significant change in the severity of the FOG. Episodes of FOG were neither related to OFF period or wearing-off phenomenon, but related to lack of adequate response to dopamine therapy. However, he discovered that when he threw a football onto the floor and kicked it, he could override his start hesitation. He could still participate fully in kickarounds and was able to run fluently with the football (see Video 1).

Gait freezing is a poorly understood phenomenon commonly observed in PD after 5- to 10-year disease duration. Recent brain activation studies have suggested that circuits involving the medial frontoparietal cortex, including the supplementary motor area, may be involved in its causation.[3] Targeted attention alone or in combination with visual, auditory, and proprioceptive cues are strategies that can be used to improve steppage and reduce freezing. Canning[4] studied patients who were instructed to pay specific attention to the act of walking at confortable speed and showed that they walked faster and with longer strides, when compared to those who did not receive similar instructions. Another study using parallel laser lines projected in front of PD patients with FOG showed that the mean duration of freezing was reduced by up to 69%, and up to 43% of the patients had fewer episodes of FOQ.[5]

Running to catch or guide a football acts simultaneously as an attentional task with sensory and visual cues and activates the dorsolateral premotor control system (voluntary), which bypasses the supplementary motor area's deficit (automatic movement).[6] It is possible that the exhilaration of a football game leads to an additional surge of catecholamines in the brain that could temporarily improve performance analogous to that described as kinesia paradoxica in earlier literature. One of us (A.J.L.) has also seen a patient who uses a football on an elastic string to improve kinetic melody and avoid freezing. It is possible that the cueing and rewarding sight of a football may also partly explain why Ray Kennedy was able to continue playing top-level professional football after his PD had begun but had not yet been diagnosed.[7]


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